Consent to Charge Credit Debit HSA FSA Card Form

When I am not present to pay in person at the time of service by Breakthru Counseling &
Consulting, P. C. (BCC), please charge fees associated with the following BCC client:



This includes charges for missed sessions not canceled within One (1) Business day of the
appointment date.

Visa, MasterCard, AMEX, Discover are accepted by BCC as are Debit cards and most Health
Savings Account ( HSA) and Flexible Spending Account (FSA) cards.
The type of card I choose from those listed above to pay for psychological services rendered by
BCC is:

AMEX
Discover
MasterCard
Visa
My Debit Card
My HSA
My FSA











By my signature below, I authorize Breakthru Counseling & Consulting, P.C. (BCC) to charge
the card I chose above for psychological services rendered to the above-named BCC client. I
voluntarily choose and ask that my typed name on the signature line of this document legally
represent my electronic signature.